The Four Pillars of Obesity TreatmentRYAN MORGAN, DO, FACOI, DIPL. ABOM, DIPL. ABCLPRESIDENT OF VITALIS METABOLIC HEALTH

Disclosures

Faculty member for Rhythm Pharmaceuticals Involved in various clinical trials: Novavax,

Moderna (none involving weight)

ObjectivesReview necessary components of screening and

evaluation for obesityDiscuss brief overview of pharmacologic

intervention, including FDA approved medications and off-label usage

Reinforce when medical or surgical referrals are appropriate

How to write a proper physical activity prescription

Review dietary approaches and adviceDiscuss a general overview of how to implement

behavioral approaches into encounter

Approaching Weight

References 1 & 2

Contributors to Weight Gain Medical issues/Medication Media Social pressures Socioeconomic status Exercise Food accessibility Energy Density Sleep Quality Sleep Duration Leisure time/play

Endocrine disrupters Epigenetics Genetics Antibiotic exposure Improving technology Work activities Habits Emotional state/Stress/Mental

Health

Reference 3

Material provided and approved for use by the © Obesity Medicine Association.

Assessment and Evaluation

Family HistoryGeneticsEpigeneticsSocio-economic

upbringing Screening

Eating DisordersSleep DisordersMood Disorders

Prior weight loss efforts ROS Physical Exam Body Composition Labs

CMP, CBC, TSH, A1c, Lipid Profile, fasting insulin level, microalbumin, β-hCG

References 4 & 5

Drug ClassWeight

Gain Drug Class Weight Gain

Anti- depressants

Amitriptyline Mirtazapine Paroxetine

MAOI Lithium

Migraine prevention

agentsBeta-blockers

Anti-hyperglycemic

Insulin Sulfonylureas

TZDs Meglitinides

Seizure Control medications

Valproate

Anti-hypertensive agents

Beta-blockersImmuno-

suppressantsGlucocorticoids

Atypical antipsychotic

agents & Mood stabilizers

Clozapine Olanzapine

Lithium Gabapentin

AntihistaminesDiphenhydramine

Hydroxyzine Cetirizine Fexofenadine

Reference 6

Hypoxia-> insulin resistance Chronic shorter sleep-> decreased leptin and

increased ghrelin Less energy -> decreased energy expenditure

Sleep Apnea

Reference 47

Binge Eating Disorder In a behavioral weight loss (BWL) study, those with CBT +

BWL lost more than CBT alone, whereas BWL had least remission in binging episodes.

Energy density education better outcomes than general nutrition education

Lisdexamfetamine is only approved medication for moderate to severe BED. Could worsen bipolar disorder and RCI in h/o addiction.

Topiramate is used off-label for BED. Weight loss with education.

References 40-46

Night Eating Syndrome (NES)

Suspected to be a shift in circadian rhythm Gold standard is CBT Rx: SSRIs, melatonin, topiramate No FDA-indicated medication Sertraline DOC Bright light therapy may help Insomnia medication contraindicated

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Surgery IndicationsASMBS

Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts

BMI > 35 with at least one or more obesity-related co-morbid condition (T2DM, HTN, OSA, OHVS, NAFLD, OA, Dyslipidemia, GI dx, or CHD)

BMI > 40, or more than 100 pounds overweight

OMABMI 30-34.9 with one or more AHC*

BMI > 35 with one or more AHC

BMI > 40 with or without AHCReferences 7 & 8

Pros Cons Expected loss in % excess

body Wt @ 2 yrs

Optimally suited for pts with

Roux-en-y Gastric Bypass

> Improvement in metab. disease

^ risk of malabsorptive complications

60-75% Higher BMI, GERD, T2DM

Vertical Sleeve Gastrectomy

Improves metab. disease; maintains Sm. Int anatomy;

infrequent nutrient deficiencies

No long-term data 50-70% Metabolic disease

Laparoscopic adjustable gastric

banding

Least invasive; removable 25-40%, 5-year removal rate internationally

30-50% Lower BMI, no

metabolic disease

Biliopancreatic diversion with

duodenal switch

MOST amount of wt loss and resolution of metabolic

disease

^ risk of nutrient deficiencies over bypass

70-80% Higher BMI, T2DM

Reference 9

Surgery Types

SymptomsObjective findings

Timing from Surgery

Common Surgery Types

Band erosion percieves no restriciton/ obstruction, pain, N/V failure of weight loss ~22 months LAGB

Band obstruction

abdominal pain, reflux, regurgitation of undigested

food post-prandially

can still gain weight if on liquid calories variable LAGB (14%)

Marginal Ulcer

abdominal pain +/-vomiting, stomal stenosis,

GI bleedingvariable 3-7 days (acute);

variable RNY (0.6-16%)

Gastro-gastric fistula

Increased capacity to ingest food, N/V, elevated WBC

associated with marginal ulcer or leak; weight

regain~25-80 days RNY (0-3%)

Intestinal SBOabdominal pain, nausea,

vomiting, obstipation

N/V, cramping abdominal pain/ inability for passing

flatus or stool

> 6 months out from surgery RNY

Reference 10

Surgery Complications

Dumping Syndrome

lightheaded, fatigue, reactive hypoglycemia, postprandial diarrhea

facial flushing within 18 months RNY (20-85)

Bleedinglightheaded, weak

a/w perforation; tachycardia,

hypotension, drop in Hgb/Hct, oliguria

within 72 hours and up to 14 days VSG, RNY

Leak/ performation

severe abdominal painperitonitis on exam;

tachycardia, fever, low urine output

within 72 hours and up to 14 days RNY, PBD/DS, VSG

SymptomsObjective findings

Timing from Surgery

Common Surgery Types

Stricture/Stomal Stenosis

post-prandial epigastric pain with frothy emesis 30% asymptomatic 4-6 weeks(3-6 mo) RNY, PBD/DS

Reference 10

Internal Hernia

intermittent post-prandial pain and/or

emesisassociated with SBO 1 week- 3 years (6-

24 mo)RNY, PBD/DS (tot 0-

5%)

Incisional HerniaPain at 1 or more

incisional sitesbulging with

valsalva/cough3-6 months after

surgeryopen procedures

(20%)

Wound infection

abdominal pain, decreased appetite

excess drainage, fevers, chills, leukocytosis,

change in bowel pattern

<30 days ALL

GB or gallstone disease

epigastric or RUQ pain, nocturnal pain to right

shoulder

elevated ALP/bili/liver enzymes/lipase,

leukocytosiswithin 6 months ALL (2-41%)

SymptomsObjective findings

Timing from Surgery

Common Surgery Types

Reference 10

Risk of Weight Regain and Long-term Weight Loss Success

Biggest Loser Study: 36% regained back to within 1% of original weight, 57% maintained >10% weight loss at 6 years

DPP: 37% maintained 7% weight loss at 3 years Look AHEAD Study: 27% maintained 10% weight loss at

8 years.

Risk of Weight Regain and Long-term Weight Loss Success

Kraschnewski JL et al: 36.6%, 17.3%, 8.5%, and 4.4% were able to maintain 5%, 10%, 15%, and 20% weight loss, respectively, at one year.

Wing RR, Phelan S: 10-20% able to maintain 5% weight loss at 5 years

Sarwer DB et al: 30-35% of lost weight is regained one year following treatment and 50% of patients will return to baseline by 5th year

NHANES (1999-2006): 1 in 6 adults with overweight/obesity reported maintaining weight loss of at least 10% for 1 year at any point in their lives

FDA indicated

Anti-Obesity Medication Common Side-effects Caveats/ConcernsPhentermine

dry mouth, constipation, insomniaCI: Glaucoma, active CHD,

Hyperthyroid, Abuse hx

Phentermine/ Topiramate

constipation, GB stones, nephrolithiasis, paresthesia, cognitive impairment

CI: Pregnancy; active CHD, uncontrolled HTN, hx kidney stones,

hyperthyroidism

Bupropion/ Naltrexonenausea, headaches CI: Hx of seizures, bulimia, opioid use

Liraglutide/Semaglutide nausea, renal impairment CI: FH medullary thyroid cancer

Orlistat"anal leakage", bloating, urinary oxalate

stones, fat-soluble vitamin deficiencyAvoid: with immunosuppressants,

untreated Vit D Deficiency

Diethylpropion dry mouth, constipation, insomniaCI: Glaucoma, active CHD,

Hyperthyroid, Abuse hx

Phendimetrazine dry mouth, constipation, insomniaCI: Glaucoma, active CHD,

Hyperthyroid, Abuse hxReference 11

Non-FDA Indicated

Anti-Obesity Medication Common Side-effects Caveats/ConcernsSGLT2-inhibitors yeast infection, UTI balanitis, amputation

Topiramate cholelithiasis, nephrolithiasis, depression, paresthesia, cognitive

impairment

CI: Pregnancy; active CHD, uncontrolled HTN, kidney stones,

hyperthyroidism

Bupropion palpitations, anxiety, headaches CI: Hx of seizures, bulimia

Other GLP-1s (excluding high dose Liraglutide and

Semaglutide

nausea, renal impairment CI: FH medullary thyroid cancer

Zonisamide Dizziness, drowsiness, nausea, decreased mental acuity

similar as topiramate as has some carbonic anhydrase inhibition

Metformin diarrhea, flatulence, nausea, bloating can increase topiramate concurrently; lactic acidosis with renal failure

Reference 12

Material provided and approved for use by the © Obesity Medicine Association.

Energy Expenditure

TDEE = RMR + TEF + NEAT + EPOC + Ex

Medical Clearance

“Cardiac events such as a heart attack or sudden death during physical activity are rare. However, the risk of such cardiac events does increase when a person suddenlybecomes much more active than usual. The greatest risk occurs when an adult who is inactive engages in vigorous-intensity activity (such as shoveling heavy snow). People who are regularly physically active have the lowest risk of cardiac events both while being active and overall.”

Physical Activity Guidelines for Americans, 2nd edition

*If patient DOES or DOES NOT exercise regularly

ACSM’s Guidelines for Ex Testing and Prescription. 10th ed. 2018, pp33-34

Activity Questions

Previous benefits of physical activity on weight loss or maintenance

Previous and current barriers to physical activity Rating ADLs (special equipment/needs/modifications) Readiness to engage Will medication need to be adjusted (e.g. DM)

Reference 13

Reference 14

Levels of Physical Activity

Reference 15

Reference 16

Exercise Prescription: FITTE

FrequencyIntensityTimeTypeEnjoyment

Material provided and approved for use by the © Obesity Medicine Association.

Comparing Diets“Overall, weight loss diminished at 12 months among all macronutrient patterns and popular named diets, while the benefits for cardiovascular risk factors of all interventions, except the Mediterranean diet, essentially disappeared.”

“Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.”

References 17 & 18

References 17

Chronobiology 700/500/200 vs 200/500/700 lost 11 more pounds at 12 weeks 50%/30%/20% vs 20%/30%/50% lost ~9 more pounds at 8 weeks 70% kcal at breakfast/lunch vs 55% lost significantly more weight loss Main meal lunch vs dinner lost more weight OGTT in 50 women with PCOS improved when breakfast largest meal

(54/35/11% VS 11/35/54%) Shift work and social jet lag have higher rates of obesity, diabetes, CVD Eating closer to natural dim-light melatonin onset, higher body fat

References 19-26

Breakfast Intervention Study 12 weeks study 1200 calorie diet Weight loss in all groups

Meal/Snack- No Standard DefinitionsMeal

Self-defined Time of day

6-10 AM (breakfast) 12-3 PM (lunch) 6-9 PM (dinner)

Largest eating occasion during these periods

All eating occasions during these periods

At least 15% total daily energy intake

Snack

Self-defined Outside of times

dedicated for meals Less than largest eating

occasion during periods outside of typical meal times

<15% of total daily energy intake

Eating Occasion

Eating/drinking providing at least 50 kcal

Separate occasions at least 15 min apart

Not based on time of day Meal distinction defined

by participants Meal = or > 15% of total

daily energy intake

Reference 19

Meal Frequency Schoenfeld et al:

Meta-analysis showing increased meal frequency lowered fat mass. Results were lost when single study was removed (Iwao et al). In calorie-controlled conditions, meal frequency did not matter. Proposed mechanism is increased thermic effect of food if association

exists Schwingshackl et al:

Meta-analysis found no statistical significance of meal frequency and weight, but lower meal frequency had smaller waist.

Sievert et al: No weight difference with changes in meal frequency but lower meal

frequency had higher total daily caloric intake. References 27-29

Fasting Fasting before 6PM vs those who eat after 6pm but fast

in AM has been shown to have reduced CRP ADF vs DCR

References 30-32

IF vs DCR No Difference when calories controlled. Metabolic

benefit

References 30-32

Material provided and approved for use by the © Obesity Medicine Association.

Motivational Interviewing Definition: Collaborative, goal-oriented method of

communication that attends to language of change for the purpose of eliciting, exploring, and strengthening a patient’s own motivation for target behavior change.

Fear = Avoidance Main Reasons for Change:

Change influenced by empathic interactionsPeople who believe they are likely to change do so

Self-perception theoryReference 33

Spirit of Motivational Interviewing

CAPE Compassion Acceptance – respecting autonomy (vs.

authority) Partnership – collaboration (vs. confrontation) Evocation - pulling from patient (vs. Imposing)

MI Principles/ProcessesPrinciples Empathy Develop Discrepancy/Explore Ambivalence Supporting self-efficacy Roll with resistance (sustain talk) Ignore the righting reflexProcesses Engaging: use OARS (open-ended questions, affirmations, reflections, summaries) Guiding/Focusing: agenda setting (what they want to get out of the interaction) Evoking: selective eliciting the reasons they are here with you Planning: moving to a change plan

MI Hill –Change TalkDARN (Preparatory Change Talk) Desire to change (want, like, wish…) Ability to change (can, could…) Reasons to change (if…then) Need to change (need, have to, go to)

CATS (Mobilizing Change Talk) Commitment to change (intend, decide,

promise…) Activation (willing, ready, preparing…) Taking Steps (started, tried…)

Reference 34

Types of Behavioral Treatment Cognitive Behavioral Therapy (CBT) – Addresses underlying thoughts and

behaviors

Dialectical Behavioral Therapy (DBT) – Developed for cognitive/ emotional dysregulated patients. Composed of mindfulness, interpersonal effectiveness, emotional regulation, distress tolerance.

Interpersonal Therapy – Can be helpful for those trying to escape discomfort or roles; validated for mood disorders; validated for grief and depression.

Normalized Eating/ Intuitive Eating – All foods fit. Maintenance meal plan and normalize behaviors first before talking about energy density.

Behavioral Weight Loss (BWL) – Lifestyle, exercise, attitudes, relationships, nutrition (LEARN). Gradual lifestyle change, moderate calorie restriction, increase PA.

Acceptance Commitment Therapy (ACT) – Focuses on acceptance, diffusion, contact with the present moment, self as context, values, committed action

References 35-39

Cognitive Behavioral Therapy

Jennifer Shapiro, PhD. Cognitive Behavioral Therapy in Obesity Treatment. OMA. April 04, 2018.

CBT Core Beliefs

Jennifer Shapiro, PhD. Cognitive Behavioral Therapy in Obesity Treatment. OMA. April 04, 2018.

Acceptance & Commitment Therapy (ACT)

Niemeier HM, et al. An acceptance-based behavioral intervention for weight loss: A pilot study. Behav Ther. 2012 Jun; 43(2): 427-435.

Questions?

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